BMJ  2007;335:1180 (8 December), doi:10.1136/bmj.39406.520498.AD

Head to head

Is infant male circumcision an abuse of the rights of the child? Yes

¹ Barnet and Chase Farm NHS Trust, Enfield, Middlesex EN2 8JL

doi: 10.1136/bmj.39406.523762.AD

Most circumcisions take place for religious rather than medical reasons. Geoff Hinchley argues that the practice is harmful and should be stopped but Kirsten Patrick believes that the future sexual health benefits justify parental choice

Improved understanding of the normal anatomy of the infant foreskin means there is now rarely a therapeutic indication for infant circumcision,¹ and the procedure is not supported by international medical opinion.² Ritual (non-therapeutic) male circumcision, however, continues unchecked throughout the world, long after female circumcision, facial scarification, and other ritual forms of infant abuse have been made illegal. The law and principles pertaining to child protection should apply equally to both sexes, so why do society and the medical profession collude with this unnecessary mutilating practice?

Ritual male circumcision is an ancient religious rite for Muslims and Jews, and the crux of this debate revolves around the primacy of parental religious conviction versus the primacy of the human rights of the child, the preservation of its bodily integrity, and its right of self determination.

In addition to religious justification, there have been many spurious and now unsupported health claims for circumcision—including the prevention of penile cancer, masturbation, blindness, and insanity³—most of which, like reduction in HIV transmission identified more recently, relate to adult sexual behaviour and not to the genital anatomy or best interest of a child. There may be a case that male circumcision reduces HIV risk in sexually active adults, but the decision about whether to have this procedure should be left until the person is old enough to make his own informed healthcare choices.

Male genital mutilation is not a risk-free procedure. There are potential anaesthetic risks, and the short term risk of bleeding and infection associated with any surgical procedure.⁴ Longer term potential complications include pain on erection, penile disfigurement, and psychological problems.⁵ A recent report shows that the non-circumcised adult penis is more sensitive than the circumcised penis, largely because the five most sensitive areas, identified in the study, are removed during circumcision.⁶ This implies a reduction in future sexual sensitivity for circumcised adults. Far from being a harmless traditional practice, circumcision damages young boys.

Legal protection

Article 24(3) of the UN convention on the rights of the child commits all ratifying states to "take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children" and article 19(1) says: "States shall take all appropriate legislative administrative social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse."⁷

UK courts have interceded in the past to protect the best interests of children whose parental belief systems have put children at risk. However, male circumcision remains lawful if both parents consent.⁸⁹¹⁰ Since the Human Rights Act has been implemented, however, single parental consent has been found to be insufficient to show that the procedure is in the child’s best interest.¹¹

As far as female genital mutilation is concerned, in the United States the Federal Prohibition of Female Genital Mutilation Act states that in applying the law, "no account shall be taken . . . that the operation is required as a matter of custom or ritual." These terms are closely mirrored in the UK Female Genital Mutilation Act 2003. Both the US and the UK legal systems therefore discriminate between the sexes when it comes to protecting boys and girls from damaging ritual genital mutilation.

The UK’s General Medical Council abdicates all responsibility for male circumcision to society as a whole,¹² but in June 2007 the BMA, which had previously offered general guidance,¹³ decided that "any decision to provide medical or surgical treatment to a child, or any decision to withhold medical or surgical treatment from a child, should: consider the ethical, cultural and religious views of the child’s parents and/or carers, but without allowing these views to override the rights of the child to have his/her best interests protected."¹⁴

Male circumcision was not specifically mentioned, but it cannot be in the best interest of a child to be subjected, without its consent, to an irreversible surgical procedure, often without anaesthetic, which will provide no medical benefit but which has proved adverse consequences both in terms of potential complications for some and reduced penile sensation in adulthood for all.

Religious perspective

Some faiths view male circumcision, often done by people who are not medically qualified, as important for entering a covenant with their God. However, given the age of the children involved it cannot be said that this covenant is freely entered into by the individual concerned.

In the US, elements of the Jewish community are beginning to rethink this issue.¹⁵ They suggest bringing Jewish boys into the covenant symbolically, with the potential for the child to be circumcised when old enough to consent to the procedure himself. Muslims already circumcise boys at an older age, and further delay to allow the child to consent could equally be considered. How much stronger would that covenant be, when entered into by a fully competent young man with full knowledge of its religious implications and the potential risks involved.

The unpalatable truth is that logic and the rights of the child play little part in determining the acceptability of male genital mutilation in our society. The profession needs to recognise this and champion the argument on behalf of boys that was so successful for girls.

doi: 10.1136/bmj.39406.523762.AD

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Competing interests: None declared.

References

1. British Association of Paediatric Surgeons, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Surgeons of England and Royal College of Anaesthetists. Statement on male circumcision. London: RCS, 2001.
2. Hofvander Y. Circumcision in boys: time for doctors to reconsider. World Hosp Health Services 2002;8(2):15-7.
3. Smith J. Male circumcision and the rights of the child. Netherlands Institute of Human Rights, 1998. www.nocirc.org/legal/smith.php.
4. Williams N, Kaplia L. Complications of circumcision. Br J Surg 1993;80:1231-6.[ISI][Medline]
5. Peterson SE. Assaulted and mutilated. A personal account of circumcision trauma. In: Denniston GC, Hodges FM, Milos MF, eds. Understanding circumcision.New York: Kluwer Academic, 2001;271.
6. Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, et al. Fine touch pressure thresholds in the adult penis. BJU Int 2007;99:864-9.[CrossRef][ISI][Medline]
7. United Nations. Convention on the rights of the child. www.ohchr.org/english/law/pdf/crc.pdf.
8. Re J (A Minor) (prohibited steps order: circumcision). [2000] 1 FLR 571.
9. Re J (child’s religious upbringing and circumcision). [2000] 1 FCR 307.
10. Re J (specific issue orders: Muslim upbringing and circumcision). [2000] 52 BMLR 82.
11. Re S. (Children) (Specific issue: circumcision) [2005] 1 FLR 236.
12. General Medical Council. Guidance for doctors who are asked to circumcise male children. London: GMC, 1997.
13. BMA. The law and ethics of male circumcision—guidance for doctors. London: BMA, 2006.
14. BMA. Annual representative meeting policies, June 2007. Ethics and professional responsibilities. www.bma.org.uk/bmapolicies.nsf/WF?OpenForm&key=Annual+Representative+Meeting.
15. Moss L. The Jewish roots of anti-circumcision arguments. Second international symposium on circumcision, San Francisco, California, 30 April-3 May 1991. www.nocirc.org/symposia/second/moss.html.

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